[Hiring] Clinical Documentation Auditor @Wellstar Health System

Role Description

The Clinical Documentation Integrity (CDI) Auditor must be good at problem-solving, clinical and coding knowledge, and communicating and collaborating. The CDI Auditor evaluates the quality and accuracy of the clinical documentation in the patient record, and works with the CDI team, providers, and coders to ensure the record shows the patient's clinical severity and level of service. The CDI auditor also looks at the performance of the CDI team and finds areas to improve.

• Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education Lead to ensure stakeholder education.
• Assists CDI Education Lead remotely with preparing provider education materials, gathering articles or other information for presentations and meetings.
• Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by management.
• Initiates audits and prepares findings to assist CDI Education Lead in preparing and providing regular CDI education to stakeholders based on findings, trends, industry events, and management needs.
• Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc.
• Conducts and provides real-time audits of reviews, queries, and reports and provides feedback on process, query opportunities, and query compliance.
• Conducts Validation and Special Project tasks to support the CDI Leadership and ensure appropriate data is entered, captured, and reported in the CDI Software for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Functions as a Super User with CDI Software and all other applications utilized in this position.
• Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician.
• Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes.
• Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post-discharge that will accurately reflect the severity and risk of mortality of the patient population.
• Ensures queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures.
• Provides appropriate follow-up on all queries.
• Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process.
• Provides appropriate follow-up to CDI Education Lead for education on queries as needed.
• Notifies CDI Education Lead immediately when query education is needed and provides all data necessary to assist in the delivery of education.
• Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
• Maintains required daily/weekly/monthly metrics and meets productivity standards.
• Participates in required departmental meetings, conference calls, and presentations.
• Adheres to departmental Policies and Procedures.
• Participates in assuring hospital compliance with Federal and State regulatory requirements.
• Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
• Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.

Qualifications

• Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine.

Requirements

• All certifications are required upon hire unless otherwise stated.
• Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 Days.
• Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred.
• It is expected that all RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required.
• It is expected that all non-clinical (coding) background candidates have at least one of the following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA Upon Hire Required.

Benefits

• Join us and discover the support to do more meaningful work—and enjoy a more rewarding life.
• Connect with the most integrated health system in Georgia, and start a future that gives you more.